A Letter to the Editor on the ancient Indian surgeon, Sushruta.

Lower limb ulcers present a common clinical problem and are at risk of malignant change. A Marjolin's ulcer has traditionally been regarded as malignant change in a long standing ulcer and/or scar tissue. We report a case of Marjolin's degeneration that developed in an ulcer only 18 months following the initial injury. Such a short latent period has not been reported for over 70 years. This report highlights the possibility of early Marjolin's change and we propose a ranked diagnostic screen to aid in early identification of possible malignant change, based on the current published evidence.

No abstract available

Background: The senior author (A.P.) has performed 70 consecutive breast reconstructions over 3 years using the free deep inferior epigastric perforator (DIEP) and pedicled extended latissimus dorsi flaps. This study set out to compare these two methods of reconstruction by looking at postoperative morphine requirements and lengths of stay in hospital. Methods: Patient notes were retrospectively reviewed and the total morphine used by patient-controlled analgesia was measured. Results: The mean morphine per kilogram required by patients who had DIEP flaps (0.21 mg/kg; n = 22) was significantly less than the amount required by patients who had extended latissimus dorsi flaps (0.47 mg/kg; n = 48; p < 0.001). An observed trend also revealed that DIEP flap patients remained in hospital for less time compared with extended latissimus dorsi flap patients, although the difference was not significant (p > 0.01). Conclusions: This study shows that DIEP flap patients require less postoperative morphine and therefore might experience less pain than extended latissimus dorsi flap patients. DIEP flap patients may also leave the hospital sooner.

No abstract available

Introduction and aims: Although once the preserve of tattoo artists, units within the UK have increasingly begun making use of the Clinical Nurse Specialist (CNS) to perform areola tattooing. Bringing the technique within the Breast Unit enhances continuity of care and makes use of skills that can be provided by the CNS. Our CNS is involved with both the patients' oncological management and the areola tattoo service. Materials and methods: The CNS-led service was investigated and patients' experiences of nipple tattooing were assessed. We present the results of a postal questionnaire and a prospective clinical audit of the procedure. Results: Forty tattoos were done over a 2-year period with one self-limiting complication. Patient satisfaction was high both with the outcome and the experience of the procedure. Fading of the tattoo is a consistent finding frequently requiring further shading. Conclusion: Overall the patient's experience of a nurse lead 'in-house' tattoo service has been highly satisfactory and this is reflected by their high confidence rating and ease of access to the nurse. We believe that the role of the CNS in oncological treatment and reconstructions helps integrate the multidisciplinary experience for the patient.

An audit of the hypospadias repair service provided in the county of Warwickshire has shown that centralising all referrals to a single surgeon who uses limited, well-practiced techniques, greatly improves outcome. Comparison to previous audit of the service, when provided by a number of surgeons in the region, shows complication rates dropping - fistulae occurrence reducing from 35.8% to 6.7% and urethral stricture rates showing similar improvement from 4.4% to 0%. Overall productivity increased, and referral out of region dropped from 13% to 0%. This provides definitive evidence that restructuring of a service already in place has decreased morbidity and increased efficiency to give results comparable to published data.